Please complete the following dialysis facility information.

*Inclusion Criteria:
Network facilities that had the highest BSI rates Healthcare-Associated Infections (HAIs) Bloodstream infections (BSIs) in the first and second quarters of 2017.
Initial Activities:
Provide the name, phone number, and email address of the project lead, back-up project lead, and any other supporting contacts in your organization via the survey below. The survey deadline due date is by 11:59PM EST, Friday , February 2, 2018.

Survey Instructions:
  • Populate all fields in the survey.
  • If the contact requested in a specific job title question is the same as the project lead or back-up project lead, enter "Same as project lead" or "Same as back-up project lead" in the name, phone number, and email address fields.
  • If your facility does not have corresponding personnel in a specific job title, enter "N/A" in the name, phone number, and email address fields.
    Survey completion is dependent on ALL fields being completed.

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* 1. Please select your facility from the dropdown list below; facility name and CMS Certification Number (CCN) have been included.

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* 2. Project Lead: 

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* 3. Project Lead Role:

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* 4. Project Lead Phone Number:
e.g. 123-456-7890

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* 5. Project Lead E-mail Address:

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* 6. Back-up Project Lead:

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* 7. Back-up Project Lead Role:

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* 8. Back-up Project Lead Phone Number:
e.g. 123-456-7890

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* 9. Back-up Project Lead E-mail Address:

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